-
Consider these risk factors:1-4 Footnotes 1 NCCN 2021. NCCN Clinical Practice Guidelines in Oncology. Survivorship. Version 2.2021. Accessed 7/13/2021
2 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
3 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
4 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
5 ASCO defines high-dose anthracycline as doxorubicin ≥250 mg/m 2, epirubicin ≥600 mg/m 2.
6 ASCO defines lower dose anthracycline as doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2.
7 ESC defines cumulative dose of anthracycline w/ high risk as doxorubicin ≥400 mg/m 2, epirubicin >900 mg/m 2, idarubicin >90 mg/m 2, liposomal anthracycline >900 mg/m 2, mitoxantrone >120 mg/m 2.
8 ESC defines type I agents as alkylating agents (ie, cyclophosphamide, ifosfamide), antimetabolites (ie, clofarabine), or antimicrotubule agents (ie, docetaxel, paclitaxel).
9 ESC defines type II agents as immuno- or targeted therapies (ie, trastuzumab, bevacizumab, petuzumab, sunitinib, pazopanib, sorafenib, dasatinib, imatinib, lapatinib, nilotinib, cafilzomib, bortezomib, everolimus, temsirolimus).
10 NCCN 2021.
• CVD (eg, CAD, CHF, peripheral vascular dz, arrhythmias)
• CVD risk factors (eg, HTN, dyslipidemia, DM, obesity, cigarette/tobacco use)
11 ASCO 2017.
• ≥2 CVD risk factors (eg, smoking, HTN, DM, dyslipidemia, & obesity) during/after completion of tx
• compromised cardiac fxn (eg, borderline low LVEF (50%-55%), hx of MI, ≥mod valvular heart dz
12 ESC 2016. CV risk factors (eg, HF, LV dysfxn, CAD, HTN, arrhythmias, DM, dyslipidemia, obesity, cigarette/tobacco use, high EtOH intake, sedentary lifestyle). -
Candidate for anthracyclines Baseline Eval Before Tx:1-4 View epocrates drug info: Footnotes 1 NCCN 2021. NCCN Clinical Practice Guidelines in Oncology. Survivorship. Version 2.2021. Accessed 7/13/2021
2 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
3 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
4 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
5 Including cardiological consultation w/ screening of CV dzs & risk factors. See also ASCVD Risk Estimator Plus Tool
6 Including LVEF measurement (ideally 3D). Use of the same imaging modality at the same facility is recommended for serial testing for each pt.
7 LVD risk, including:
• High-dose anthracycline (eg, doxorubicin ≥250 mg/m 2, epirubicin ≥600 mg/m 2)
• High-dose RT (≥30 Gy) where the heart is in the treatment field
• Lower-dose anthracycline (eg, doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2) in combo w/ lower-dose RT (<30 Gy)
• Tx w/ lower-dose anthracycline (doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2) or trastuzumab alone, and presence of any of the following risk factors:
- Multiple CV risk factors (≥2 risk factors), incl smoking, HT, DM, dyslipidemia, and obesity, during or after completion of therapy
- Older age (≥60 yo) at cancer tx
- Compromised cardiac fxn (eg, borderline low LVEF (50% to 55%), MI hx, ≥moderate valvular heart dz) at any time before or during tx
• Tx w/ lower-dose anthracycline (doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2) followed by trastuzumab (sequential therapy)
8 Anthracycline-equivalence dose to doxorubicin rapid infusion 400 mg/m 2:
• 900 mg/m 2 epirubicin
• 800 mg/m 2 daunorubicin
• 150 mg/m 2 idarubicin
Candidate for HER2 inhibitors Baseline Eval Before Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Including cardiological consultation w/ screening of CV dzs & risk factors. See also ASCVD Risk Estimator Plus Tool
5 Including LVEF measurement (ideally 3D). Use of the same imaging modality at the same facility is recommended for serial testing for each pt.
6 LVD risk, including:
• High-dose anthracycline (eg, doxorubicin ≥250 mg/m 2, epirubicin ≥600 mg/m 2)
• High-dose RT (≥30 Gy) where the heart is in the treatment field
• Lower-dose anthracycline (eg, doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2) in combo w/ lower-dose RT (<30 Gy)
• Tx w/ lower-dose anthracycline (doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2) or trastuzumab alone, and presence of any of the following risk factors:
- Multiple CV risk factors (≥2 risk factors), incl smoking, HT, DM, dyslipidemia, and obesity, during or after completion of therapy
- Older age (≥60 yo) at cancer tx
- Compromised cardiac fxn (eg, borderline low LVEF (50% to 55%), MI hx, ≥moderate valvular heart dz) at any time before or during treatment
• Tx w/ lower-dose anthracycline (doxorubicin <250 mg/m 2, epirubicin <600 mg/m 2) followed by trastuzumab (sequential therapy)
7 Anthracycline-equivalence dose to doxorubicin rapid infusion 400 mg/m 2:
• 900 mg/m 2 epirubicin
• 800 mg/m 2 daunorubicin
• 150 mg/m 2 idarubicin Candidate for VEGF inhibitors Baseline Eval Before Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Including cardiological consultation w/ screening of CV diseases & risk factors. See also ASCVD Risk Estimator Plus Tool
5 Including LVEF measurement (ideally 3D). Use of the same imaging modality at the same facility is recommended for serial testing for each pt. Candidate for Bcr Abl kinase inhibitors bosutinib, dasatinib, imatinib Bcr-Abl kinase inhibitors can cause accelerated atherosclerosis, peripheral artery dz development, acute coronary syndrome, stroke, HTN, hyperglycemia, hypercholesterolemia, pericardial effusion, pulmonary arterial HTN, QTc prolongation, & occasionally LVSD1 Baseline Eval Before Tx:1-4 View epocrates drug info: Footnotes 1 FrenchCardioOnc 2020. Joachim A, et al. French Cardio-Oncology Working Group. Cardiovascular Toxicity Related to Cancer Treatment: A Pragmatic Approach to the American and European Cardio-Oncology Guidelines. J Am Heart Assoc. 2020. Sept 15;9(18):e018403. Free full-text PDF @ PubMed® Central
2 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
3 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
4 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
5 In absence of GLS quantification of LV longitudinal fxn, use mitral annular displacement by M-mode echocardiography and/or peak systolic velocity of mitral annulus by pulsed-wave DTI. Bcr-Abl kinase inhibitors can cause accelerated atherosclerosis, peripheral artery dz development, acute coronary syndrome, stroke, HTN, hyperglycemia, hypercholesterolemia, pericardial effusion, pulmonary arterial HTN, QTc prolongation, & occasionally LVSD1 Baseline Eval Before Tx:1-4 View epocrates drug info: Footnotes 1 FrenchCardioOnc 2020. Joachim A, et al. French Cardio-Oncology Working Group. Cardiovascular Toxicity Related to Cancer Treatment: A Pragmatic Approach to the American and European Cardio-Oncology Guidelines. J Am Heart Assoc. 2020. Sept 15;9(18):e018403. Free full-text PDF @ PubMed® Central
2 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
3 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
4 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
5 In absence of GLS quantification of LV longitudinal fxn, use mitral annular displacement by M-mode echocardiography and/or peak systolic velocity of mitral annulus by pulsed-wave DTI. Bcr-Abl kinase inhibitors can cause accelerated atherosclerosis, peripheral artery dz development, acute coronary syndrome, stroke, HTN, hyperglycemia, hypercholesterolemia, pericardial effusion, pulmonary arterial HTN, QTc prolongation, & occasionally LVSD1 Baseline Eval Before Tx:1-4 View epocrates drug info: Footnotes 1 FrenchCardioOnc 2020. Joachim A, et al. French Cardio-Oncology Working Group. Cardiovascular Toxicity Related to Cancer Treatment: A Pragmatic Approach to the American and European Cardio-Oncology Guidelines. J Am Heart Assoc. 2020. Sept 15;9(18):e018403. Free full-text PDF @ PubMed® Central
2 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
3 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
4 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
5 In absence of GLS quantification of LV longitudinal fxn, use mitral annular displacement by M-mode echocardiography and/or peak systolic velocity of mitral annulus by pulsed-wave DTI. Candidate for proteasome inhibitors Baseline Eval Before Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Including cardiological consultation w/ screening of CV diseases & risk factors. See also ASCVD Risk Estimator Plus Tool
5 Including LVEF measurement (ideally 3D). Use of the same imaging modality at the same facility is recommended for serial testing for each pt. Ibrutinib can cause atrial fibrillation (AF), and is also assoc w/ HTN, HF, ventricular arrhythmias, & conduction disorders1 Baseline Eval Before Tx:2-5 View epocrates drug info: Footnotes 1 Salem J-E, et al. Cardiovascular Toxicities Associated With Ibrutinib. J Am Coll Cardiol. 2019. Oct 1;74(13):1667–1678. Accessed 7/2/21
2 FrenchCardioOnc 2020. Joachim A, et al. French Cardio-Oncology Working Group. Cardiovascular Toxicity Related to Cancer Treatment: A Pragmatic Approach to the American and European Cardio-Oncology Guidelines. J Am Heart Assoc. 2020. Sept 15;9(18):e018403. Free full-text PDF @ PubMed® Central
3 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
4 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
5 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
6 In absence of GLS quantification of LV longitudinal fxn, use mitral annular displacement by M-mode echocardiography and/or peak systolic velocity of mitral annulus by pulsed-wave DTI. Candidate for immune checkpoint inhibitors Baseline Eval Before Tx:1-3 Monitoring After Tx:1-3
- ESMO, ASCO, & ESC provide no recommendations for monitoring after tx
View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2018. Brahmer JR, et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Check-Point Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2018. June 10;36(17):1714–1768. Free full-text PDF @ PubMed® Central
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Including cardiological consultation w/ screening of CV diseases & risk factors. See also ASCVD Risk Estimator Plus Tool
5 Including LVEF measurement (ideally 3D). Use of the same imaging modality at the same facility is recommended for serial testing for each pt. -
Candidate for anthracyclines Primary Prevention Before Tx:1-3 Primary Prevention During Tx:1-3 Primary Prevention After Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021 Candidate for HER2 inhibitors Primary Prevention Before Tx:1-3 Primary Prevention During Tx:1-3 Primary Prevention After Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021 Candidate for VEGF inhibitors Primary Prevention Before Tx:1-3 Primary Prevention During Tx:1-3 Primary Prevention After Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Diltiazem & verapamil are typically contraindicated, per ESMO, since they are inhibitors of cytochrome P450 3A4 (CYP3A4) resulting in increased VEGF-signaling pathway inhibitor levels. Candidate for Bcr-Abl kinase inhibitors Primary Prevention Before Tx:1-3 Primary Prevention During Tx:1-3 Primary Prevention After Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Diltiazem & verapamil are typically contraindicated, per ESMO, since they are inhibitors of cytochrome P450 3A4 (CYP3A4) resulting in increased VEGF-signaling pathway inhibitor levels. Candidate for proteasome inhibitors Primary Prevention Before Tx:1-3 Primary Prevention During Tx:1-3 Primary Prevention After Tx:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 Diltiazem & verapamil are typically contraindicated, per ESMO, since they are inhibitors of cytochrome P450 3A4 (CYP3A4) resulting in increased VEGF-signaling pathway inhibitor levels. -
Cardiac (left ventricular) dysfxn Definitions & Management:1-3 asymptomatic pts undergoing anthracycline tx w/ LVEF decrease ≥10% from baseline to 50%, or LVEF drop to ≥40% but <50%:1 - obtain cardiology consult (prefer cardio-oncology specialist)
- consider initiating cardioprotective tx (ACEI, ARB, and/or BB), if not already prescribed
- consider statin if concomitant coronary dz present
- consider BNP or NT pro-BNP and troponins & cardiac-focused PE after each anthracycline dose
- repeat LVEF assessment after alternate doses of anthracyclines
- if planning further anthracycline-based chemotx: discuss risk/benefits of continued use vs non-anthracycline regimen options; consider use of dexrazoxane and/or liposomal doxorubicin
asymptomatic pts undergoing trastuzumab tx w/ LVEF decrease ≥10% from baseline, or LVEF drop to ≥40% but <50%:1 - obtain cardiology consult (prefer cardio-oncology specialist)
- consider initiating cardioprotective tx (ACEI, ARB, and/or BB), if not already prescribed
- consider BNP or NT pro-BNP and troponins monthly & periodic, cardiac-focused PE
- if trastuzumab stopped, repeat LVEF w/in 3-6wk, & resume trastuzumab tx if LVEF normalizes to >50%
- OK to continue trastuzumab tx w/ mild asymptomatic reductions in LVEF
- OK to stop HF tx after normalization, per ESC3
pts undergoing trastuzumab tx (or any HER2-targeted molecular tx) w/ HF s/sx, or asymptomatic pts w/ LVEF <40%:1 - same (above) assessments as those for an LVEF ≥40% are recommended, plus
- withhold trastuzumab (or any HER2-based tx) until cardiac status has stabilized; involve multidisciplinary team to discuss risks/benefits of continuing w/ pt
pts w/ interrupted trastuzumab tx (or any HER2-targeted molecular tx), w/ LVEF ≥40% and/or w/ resolved HF s/sx:1 - may resume trastuzumab tx, assuming continued HF medical tx & ongoing cardiology care
- obtain periodic cardiac biomarker/LVEF assessments during ongoing treatment
pts w/ interrupted trastuzumab tx (or any HER2-targeted molecular tx), but w/ unresolved HF s/sx and/or LVEF <40%:1 - OK to resume trastuzumab tx if no alternative therapeutic option exists
- involve multidisciplinary team to discuss risk/benefits of cancer prognosis vs HF w/ pt
pts w/ HF s/sx undergoing sunitinib tx (or other anti-VEGF-based tx):1 - assess/optimize BP control & consider LVEF measurement and/or cardiac biomarkers
- interrupt sunitinib tx (or other anti-VEGF-based tx), then assess pt to decide if appropriate to reinstitute those therapies
pts who developed LVD or HF d/t any anticancer therapies:1 - continue CV care incl med tx w/ ACEI, ARB, and/or BB & regular cardiology review (eg, annual if asymptomatic) indefinitely, regardless of improvement in LVEF or sx
- withdraw HF-based tx only after a period of stability, no active cardiac risk factors, & no further active anticancer tx
View epcorates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021 Subclinical left ventricular dysfxn Definitions & Management:1-3 asymptomatic pts undergoing any cardiotoxic anticancer tx w/ normal LVEF but decrease in average GLS ≥12% relative decrease from baseline, or ≥5% absolute decrease from baseline:1 - consider initiating cardioprotective tx (ACEI, ARB, and/or BB), if not already prescribed
- repeat TTE w/ GLS q3mo
- life-saving chemotx should not be altered solely based on GLS changes
asymptomatic pts undergoing any cardiotoxic anticancer tx w/ an elevation in troponin:1 - obtain cardiology consult (prefer cardio-oncology specialist)
- consider TTE w/ GLS
- r/o ischemic heart dz as comorbidity
- consider initiating cardioprotective tx (ACEI, ARB, and/or BB), if not already prescribed
- consider initiating dexrazoxane in pts w/ anthracyclines
- continue chemotx w/o interruption only if mild elevations in cardiac biomarkers w/o significant LVD
View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 This decrease should be confirmed by repeated imaging done after 2-3wk. Definitions & Management:1-3 View epocrates drug info: Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 HTN should be adequately treated to these targets, per 2017 ACC/AHA guidelines; however, this threshold for treatment has not been tested in the cancer population.
5 The non-dihydropyridine calcium channel blockers (diltiazem and verapamil) are typically contraindicated d/t risk of drug-drug interactions.
6 Diuretics have risk of electrolyte depletion and consequent QT prolongation; although they may be used, caution is advised. QTc interval prolongation Definitions & Management:1-3 Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021 Definitions & Management:1-3 Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2017. Armenian SH, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017. Mar 10;35(8):893-911. Accessed 5/28/2021
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 For table of agents assoc w/ afib, see ESC 2016, Table 8. Accessed 5/28/2021 Immune checkpoint inhibitor-related myocarditis Definitions & Management:1-3 pts w/ new CV sx or incidentally noted to have any arrhythmia, conduction abnormality on ECG or LVSD on ECG, while undergoing/recently completing ICI tx:1 - promptly carry out further appropriate work-up (ECG, troponin, BNP or NT-pro-BNP, C-reactive protein, viral titer, ECG w/ GLS, cardiac MRI) for ICI-associated CV toxicity, esp for myocarditis & other common differential dx
pts w/ elevated troponin or conduction abnormalities:2
- offer immediate transfer to coronary care unit
pts w/o immediate response to high-dose corticosteroids:2 - offer early institution of cardiac-transplant rejection doses of corticosteroids (methylprednisolone 1 g every day) plus either mycophenolate, infliximab, or antithymocyte globulin
pts in whom dx highly suspected but w/ otherwise negative w/u:1 - consider endomyocardial bx
pts w/ either suspicion/confirmation of ICI-associated myocarditis:1 - withhold further ICI tx
- promptly initiate high-dose corticosteroids (methylprednisolone 1000 mg/day, followed by oral prednisone 1 mg/kg/day)
- continue corticosteroids until sx resolution & normalization of troponin, LV systolic fxn, & conduction abnormalities
pts w/ steroid-refractory/high-grade myocarditis w/ hemodynamic instability:1
- consider other immunosuppressive tx (eg, anti-thymocyte globulin, infliximab, except in pts w/ HF)
- pts w/ HF: consider mycophenolate mofetil or abatacept
pts w/ cardiomyopathy and/or HF:1 - provide appropriate guideline-directed medical tx & hemodynamic support
pts w/ atrial or ventricular tachyarrhythmia or heart block:1 - provide appropriate medical & supportive care
pts w/ any clinical myocarditis:1 - permanently d/c ICI tx
- any decision to restart ICI tx in absence of alternative available antineoplastic tx needs to be individualized w/ multidisciplinary discussion (incl cancer status, response to prior tx, severity of cardiotoxicity, regression of toxicity w/ immunosuppressive tx) & pt preference after weighing risks/benefits
- if restarting ICI tx: consider monotx w/ anti-programmed cell death protein 1 (anti-PD-1) agent & survey very closely for any cardiotoxicity development
Footnotes 1 ESMO 2020. Curigliano G, et al. Management of Cardiac Disease in Cancer Patients Throughout Oncological Treatment: ESMO Consensus Recommendations. ESMO Guidelines Committee. Ann Oncol. 2020. Feb;31(2):171–190. Free full-text PDF @ PubMed® Central
2 ASCO 2018. Brahmer JR, et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Check-Point Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2018. June 10;36(17):1714–1768. Free full-text PDF @ PubMed® Central
3 ESC 2016. Zamorano JL, et al. 2016 ESC Position Paper on Cancer Treatments and Cardiovascular Toxicity Developed Under the Auspices of the ESC Committee for Practice Guidelines: The Task Force for Cancer Treatments and Cardiovascular Toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Sept 21;37(36):2768–2801. Accessed 5/28/2021
4 See 2017 ACC/AHA Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018. May 15;71(19):2199-2269. Accessed 7/14/21
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